The eyes of the Ministry of Health and a shield to protect the communitys health

By Sally Theobald, Liverpool School of Tropical Medicine

We held the first REACHOUT analysis workshop in Malawi (2nd-6th September) exploring the data collected by the REACH Trust team for the context analysis. I spent 18 months as technical adviser at REACH Trust from 2004-6, and it was excellent to return, greet old friends and see the Trust growing and consolidating under Ireen Namakhoma’s able leadership. The Reach Trust 9 person strong REACHOUT research team had just returned from collecting qualitative data with Health Surveillance Assistants (HSA’s, Malawi’s key ‘close-to-community’ providers), communities and key informants in Mchinji (which borders Zambia) and Salima (which is on the shores of Lake Malawi). We spent the first morning having an in-depth debrief with the research team, hearing about the process of data collection, their initial impressions of the data they collected, what was surprising, what was memorable and the cultural and contextual differences between Mchinji and Salima.

The REACHOUT research team divided up the interviews and focus group discussions depending on availability of informants and met for debriefing every evening to share experiences, discuss inconsistencies, update notes and review the purposive sampling frame. During the debriefings, Lot Nyirenda who supervised the data collection team, challenged the team to interrogate key recurring themes from the data (sustainability of programmes, role of incentives and motivation) from multiple perspectives and through doing so better understand varying viewpoints and competing narratives that emerged. This highlighted for me how good quality qualitative research is like being a detective, unravelling and understanding the why and the how of behaviours and what motivates and sustains interactions. This is important in the REACHOUT context analysis which brings a holistic health systems analysis to understanding the multiple interactions between close-to-community providers, health systems and communities, in order to work out ways to intervene in two sets of quality improvement cycles.

We spent the next days, sitting in REACH Trust’s beautiful garden reading, coding and discussing transcripts in pairs and then in the plenary. I read interviews with HSAs and focus group discussions with community members (such as mums with young children). These confirmed for me the central and pivotal role of HSAs as a bridge between health systems and communities, and how critical these are in hard to reach communities, such as rural Mchinji. One HSA referred to their role as being ‘the eyes’ of the Ministry of Health and ‘a shield’ to protect the community’s health. I look forward to working with the team on the unfolding analysis and with stakeholders at national and district level to identify the substance of quality improvement cycles to support the pivotal and critical work of HSAs in driving forward universal health coverage.